Lord Darzi's next stage review talks about increasing clinical leadership in the NHS. By encouraging leaders to be practitioners, partners and leaders, he hopes to drive through the quality agenda.

But what sort of clinical leaders are we looking for, who will they be, what sort of skills and attributes will they need? Are we looking for leaders with clinical skills and knowledge, or are we looking for clinicians with leadership skills?

Are we looking for clinical leaders or clinical managers? There are some inherent differences between management and leadership skills; clinical skills are different again. If we are looking for leaders who are clinicians, should they still be practising? If not, then how current should their clinical knowledge be?

It is unlikely that one size will fit all. The NHS - nationally and locally - needs to be good at identifying clinicians with a natural flair for leadership and innovation and encourage and develop them. Lord Darzi seems to have embraced this idea with wide-reaching initiatives to develop clinical leadership.

Doctors, GPs and consultants have often seemed to find it easier to move into clinical leadership roles while maintaining the respect of their peers. But the time will come, if they are to move into executive roles, as Lord Darzi seems to be implying, that the pressure of being practising clinicians and high-level leaders will become too difficult. Decisions will need to be made as to which side of the fence they sit on. If they are to cross over permanently to the "dark side" of management, will they lose some of their clinical credibility and the respect of their peers? In the future, with these new reforms, it is hoped not.

Leaders in nursing

Nurses have had a different experience. There are many nurses who have reached senior and executive positions, but this has always been at the expense of their clinical careers. It is a decision many nurses have had to make as they move up the career ladder: do they move into a better paying managerial role or stay working at a clinical level.

Over the last 15 years, however, advanced nursing and specialist nursing roles have developed, enabling some nurses to reach higher levels while maintaining a clinical focus. This has been an important development for nursing. However, there remains a wide gulf between clinicians and senior management in terms of pay and influence.

When PCTs are recruiting to professional executive committees, which many see as the driver for effective clinical leadership and engagement, it has sometimes been a challenge to find candidates from frontline nursing roles who also have the relevant leadership and strategic awareness needed to function effectively on a PEC. There are not many practising nurses who recognise that they have the relevant skills and attributes and there seems to be a reluctance to step forward. Perhaps professional prejudices remain which make them feel that their voice, opinions and views will not be heard or valued.

But as we have seen from Lord Darzi's next stage review, times are changing for clinicians in the NHS. This is a time for them to step up to the challenge of leadership, to take the real opportunity to influence change at the highest level, as well as locally, to ensure that quality and effective services are commissioned and delivered in the most appropriate place for the populations we serve. This needs to start soon, at all levels, in all professions. Clinical leadership has to become an acceptable path for clinicians to take and one that will be both professionally and financially rewarding.